Published April 19, 2021
SERIOUS EMOTIONAL
DISTURBANCE (SED)
Home and Community Based Services (HCBS)
Program Manual
2021 Edition
K A N S A S D E P A R T ME N T F O R A G IN G A N D D I S A B IL I T Y S E R VI C E S
Serious Emotional Disturbance (SED)
Program Manual
Kansas Department for Aging and Disability Services
New England Building
503 S. Kansas Ave,
Topeka, KS 66603
Table of Contents
Table of Contents ....................................................................................................................................................................... i
Table of Figures ......................................................................................................................................................................... 2
Acronyms ................................................................................................................................................................................... 2
Terms and Definitions ............................................................................................................................................................... 3
SED Waiver Eligibility Requirements ...................................................................................................................................... 6
Steps for Determining SED Level of Care ................................................................................................. 7
Exceptions to SED Waiver Criteria ............................................................................................................. 8
Steps for requesting Initial Exception to SED Wavier Criteria ................................................................ 9
Notice of Action Requirements ................................................................................................................... 9
Financial Eligibility...................................................................................................................................... 10
Client Obligation ........................................................................................................................................ 10
Kansas Medical Assistance Plan (KMAP) Website................................................................................ 11
SED Waiver Services ............................................................................................................................................................. 12
Parent Support and Training .................................................................................................................... 12
Independent Living/Skills Building .......................................................................................................... 14
Short Term Respite Care .......................................................................................................................... 15
Wraparound Facilitation ............................................................................................................................ 16
Professional Resource Family Care ........................................................................................................ 17
Attendant Care [§1915(c)] / Personal Care (waiver language) ........................................................... 18
One Waiver Service Monthly Requirement ............................................................................................ 19
Person-Centered Service Plan ............................................................................................................................................. 21
Wrap-around team ..................................................................................................................................... 21
The purpose of the Person-Centered Service Plan is to: ..................................................................... 21
Essential elements to the Person-Centered Service Plan document include: .................................. 22
Natural supports ........................................................................................................................................ 22
Goals and Objectives ................................................................................................................................ 22
Strengths and Needs Assessment .......................................................................................................... 22
Crisis Plan ................................................................................................................................................... 23
Below are some guidelines in developing effective crisis plans. ........................................................ 23
Person-Centered Service Plan: Reviews ............................................................................................... 24
Person Centered Service Plan review: ................................................................................................... 24
Person Centered Service Plan:................................................................................................................ 24
Annual Eligibility Reviews ......................................................................................................................... 24
Annual Wraparound Meeting: .................................................................................................................. 25
Transfers .................................................................................................................................................................................. 26
Responsibilities of the Transferring CMHC ............................................................................................ 26
Responsibilities of Receiving CMHC ....................................................................................................... 27
When people move without notice .......................................................................................................... 27
More Than One Center Providing Waiver Services to a Waiver Participant ..................................... 29
SED Waiver Closure .................................................................................................................................. 30
Prohibited Restrictive Interventions and the Use of Restraint ............................................................................................... 32
Basis for use of restraint ........................................................................................................................... 33
Duties related to the use of restraint ....................................................................................................... 33
Staff training related to the use of restraint ............................................................................................ 34
Documentation requirements related to the use of restraint ............................................................... 34
Review of the use of restraint ................................................................................................................... 35
Billing Information ...................................................................................................................................... 36
Attachments: SED Manual Forms ........................................................................................................................................ 37
Table of Figures
Figure 1: Process Map: Steps for Determining SED Waiver Eligibility .................................... 8 Figure 2: Process Map: Exceptions.............................................................................................. 9 Figure 3: SED Waiver 3160 Flowchart ...................................................................................... 10 Figure 4: Process Map: Transfers (Planned transfer with notice from family) .................... 28 Figure 5: Process Map: When people move without notice .................................................. 29
Acronyms
AC – Attendant Care
CAFAS – Child and Adolescent Functional Assessment Scale
CBCL – Child Behavior Check List
DCF – Department for Children and Families
HCBS – Home and Community Based Services
ICE Form – Initial Clinical Eligibility Form
JJA - Juvenile Justice Authority
KDADS – Kansas Department for Disability and Aging Services
KDHE – Kansas Department for Health and Environment
MCO – Managed Care Organization
PECFAS: Preschool and Early Childhood Functional Assessment Scale.
PRFC – Professional Resource Family Care
PST – Parent Support and Training
QMHP – Qualified Mental Health Professional
SED – Serious Emotional Disturbance
WAF – Wraparound Facilitation or Wraparound Facilitator
Terms and Definitions
Annual Review
A clinical evaluation of the waiver participant by a Qualified Mental Health Professional
(QMHP) to determine if a waiver participant meets clinical eligibility requirements in order
to continue to receive waiver services. The annual review occurs each year during the 30
days prior to the date of the previous assessment.
CAFAS
Child and Adolescent Functional Assessment Scale. An assessment tool/rating scale
which assesses a youth’s degree or impairment in day-to-day functioning due to
emotional, behavioral, psychological, psychiatric, or substance use issues.
CBCL
Child Behavior Checklist. An assessment tool designed to define child behavioral
problems empirically and assess in a standardized format the behavioral problems and
social competencies of children as reported by parents, teachers, or the youth himself or
herself. The versions of the CBCL include the parent/guardian form, Teacher Report (TR),
and Youth Self Report (YSR).
ES-3160
A Kansas Department of Health and Environment (KDHE) document used by the CMHC
to notify Kansas Department for Aging and Disability Services and KDHE that the waiver
participant has met clinical eligibility requirements for the SED Waiver and that financial
eligibility needs be established.
An MCO or Medicaid eligibility staff may submit a 3160 to the CMHC to request a clinical
eligibility determination for a person they believe may be eligible for the SED Waiver
ES-3161
A KDHE document completed by the CMHC or MCO to notify KDADS and KDHE of
changes to a waiver participant’s eligibility status or other change in demographic/provide
The Functional Eligibility denial will trigger a state fair Hearing. 33 days.
Functional eligibility needs to be reviewed and approved by the KDADS Program
Manager. The ES-3161 is sent to KDADS after the annual review if level of care is not
met. The KDADS Program Manager will review and approve and forward to KDHE for
closure and NOA distribution. KDHE will notify KDADS, CMHC and MCO by completed
3161.
Exception request
Exceptions to certain clinical eligibility requirements can be made in circumstances when
adequate documentation exists to justify why the exception should be made. Clinical
eligibility exceptions can be approved based on the waiver participant’s minimum age,
maximum age, and CBCL score. Eligibility exception requests comes through KAMIS to
the KDADS SED Program Manager to be approved or denied (see the exception criteria
in this manual).
Initial Clinical Eligibility Form (ICE Form)
SED Waiver clinical eligibility document completed by QMHP that includes eligibility
determination worksheet, Criteria for Serious Emotional Disturbance worksheet
(previously Attachment B), and Current Evidence Supporting Child/Youth’s SED Waiver
Status (previously Attachment D).
Kansas Department for Aging and Disability Services
Community Services and Programs Commission oversees the Home and Community
Based Services’ Serious Emotional Disturbance Waiver Program which provides children
with mental health conditions special intensive support to help them remain in their
homes and communities. The state agency administers the Serious Emotional
Disturbance Waiver. Program Manager for SED Waiver is the point of contact.
Kansas Behavioral Health Services Commission manages mental health services in
Kansas, working with 26 community mental health centers across the state. In addition, it
oversees addiction and prevention service programs for the State of Kansas, including
target workforce development initiatives. The commission is also charged with
overseeing the state’s two psychiatric hospitals.
Notice of Action (NOA)
A document sent to the waiver participant/s parent/guardian by the State notifying Waiver
Participants of changes or eligibility. MCO send out NOA when there is an adverse action
to the participant’s service plan. (60+3 days) For a closure the MCO will send a 3161 to
KDADS. The KDADS Program Manager will review, sign the 3161, and send to KDHE.
NOA will be sent as appropriate by KDHE.
Person Centered Service Plan or "Service Plan" (not PCSP which is an IDD waiver
term)
The service plan must be developed through a person-centered planning process,
managed by the MCO. It reflects the individual's strengths and preferences, clinical and
support needs, goals and desired outcomes, and the providers of services/supports,
including unpaid supports provided voluntarily in lieu of waiver or state plan home and
community-based services.
Personal Interest Inventory
Tool used by the MCOs to gather specific information on the waiver participant to
develop the Person Centered Service Plan.
PECFAS
Preschool and Early Childhood Functional Assessment Scale. The assessment tool used
for children who are under 5 or not yet in school. The PECFAS can also be used for older
children functioning at a lower developmental level. Children 5 and older or who are in
Kindergarten or a higher grade are given the CAFAS.
Plan of Care
The treatment planning document developed by the Community Mental Health Center.
This outlines the waiver participant’s identifying information, strengths and needs,
treatment goals, treatment objectives, crisis plan, services to be provided to meet the
youth’s emotional well-being. Used in wrap around process. Plan of care is a component
of the Person Centered Service Plan which the MCO will develop. (Note: CMHC develops
a “plan of care” not a “service plan to work off of from until the MCO develops their
Person Center Service Plan (which is important for waiver compliance).
Provisional Plan of Care
Temporary financial plan of care created during the eligibility process which allows the
CMHC to start services before the Person Centered Service Plan is created by the MCO
outlining the approved service plan. It also shows that there is at least one Wavier service
the child can access.
Qualified Mental Health Professional
A Master’s level clinician who is licensed by the Kansas Behavioral Sciences Regulatory
Board or an ARNP, PA or MD and employed by a CMHC that determines initial and
continued clinical eligibility for the SED Waiver consumers.
Wraparound Facilitator
A mental health professional employed by a CMHC and is responsible for the
development of the Plan of Care and arranging and monitoring waiver service provision.
Wraparound Team
The Wraparound Team consists of the waiver participant, parent(s)/guardian(s), family,
friends, natural supports, mental health professionals, and any other person chosen by
the family to participate in the development of the Person Center Service Plan. The
Wraparound team develops the Person -Centered Service Plan with the MCO.
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SED Waiver Eligibility Requirements
A community mental health center (CMHC) must complete a clinical evaluation to determine if a child/youth qualifies
for the SED Waiver. In order to qualify for waiver services, the child/youth must meet the minimum criteria, and
eligibility must be established in the correct order. Those criteria are listed below.
I n p a t i e n t P s y c h i a t r i c C r i t e r i a 1. In the absence of HCBS/SED services a waiver participant must be determined as likely to need inpatient
psychiatric hospitalization level of care as described in 42 CFR 440.160
D i a g n o s i s 1. A mental health diagnosis identified in the current DSM
2. Diagnoses V codes, substance abuse or dependence, and intellectual or developmental disorders cannot
be the sole diagnosis and must co-occur with a qualifying mental, behavioral, or emotional disorder.
S e r i ou s E m o t i on a l D i s t u r b a n c e ( SE D ) c r i t e r i a 1. Must meet SED criteria.
2. Transitional age youth can be designated as both SED and SPMI. _If the Waiver participant is on the waiver,
SED should be marked in AIMS.
F u n c t i on a l A s s e s s m e n t 1. All SED waiver participants must meet minimum scores on the Child Adolescent Functional Assessment
Scale {CAFAS) and the Child Behavior Checklist (CBCL). All versions of the CBCL are acceptable.
a. The minimum total score for the CAFAS is 100, or 30 on any two subscales.
b. The CAFAS can only be administered and scored by a Qualified Mental Health Professional
(QMHP).
c. The minimum score for the CBCL is a t-score of 70 on any of the 3 subscales.
i. An exception for subscale scores 63 through 69 may be requested using the exception
process outlined on page 9 of the manual.
2. CMHC service providers can assist in obtaining CBCL results (e.g. helping the family understand the
instrument and questions).
A g e 1. A waiver participant must be between the ages of 4 and 18; although a request for eligibility exception may
be submitted for a child younger than 4, and older than 18 through the age of 21. The exception must be
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approved by KDADS SED Waiver Manager following the defined exception process on page 9 of the
manual. The approved and signed age exception form by KDADS Program Manager must be kept on file.
2. At youth's Annual Review during their 18th year, follow the process outlined in Section C of Annual
Evaluation of Level of Care for requesting approval of ongoing eligibility for youth over 18.
3. If a waiver participant is over the age of 18, he or she can become eligible for the SED Waiver through age
21 provided they have been identified as having a serious emotional disturbance and received rehabilitative
community based services any time during the 180 days prior to turning age 18, or would have accessed
community based services during that time period but were unable due to their institutional or residential
status, provided they continue to meet the functional and financial eligibility criteria.
Steps for Determining SED Level of Care
The steps for determining SED Level of Care are:
1. The child has to meet SED criteria (see eligibility criteria)
2. Complete the CAFAS, CBCL, and Initial Clinical Eligibility (ICE) Form
a. Coordinate with KU 3rd party assessor if applicable to complete the CAFAS. QMHP will complete
the CAFAS and record subscales, assessment total and date. Completed on the ICE Form. CAFAS
form (paper or electronic) must be signed by the QMHP with credentials and date and maintained
in the clinical record.
b. The CAFAS must be completed within 90 calendar days before the clinical eligibility date. If the
CAFAS does not meet the minimum threshold, the child is NOT eligible for the HCBS SED Waiver.
i. The minimum total score is 100, or 30 on any 2 subscales.
c. Complete the CBCL and record the t-score for the CBCL subscales, and date completed on the
ICE Form.
d. The CBCL must be completed within 180 calendar days before the clinical eligibility date. The
minimum t score for any of the three subscales is 70. If the subscales do not meet the threshold
but fall between 63 and 69, CBCL exception can be requested. If the subscales are 62 or below,
the child is not eligible for the HCBS SED Waiver.
e. If a CBCL exception is required, the QMHP must submit an eligibility exception request (Attachment
D) for the CBCL score to the KDADS SED Waiver Program Manager. The date of the eligibility
exception request approval becomes the clinical eligibility date.
3. The youth (if 18) or legal guardian completes the Medicaid Application online to complete the financial
eligibility. If the child/youth is already on Medicaid, proceed to #7. CMHC staff may assist the guardian/youth
in completing this process. When the application is “submitted” the system will give a confirmation #. Print
this page to send with the 3160 to KDHE.
4. A strength and needs assessment and provisional plan of care is developed with the child/youth/family to
include the services that are needed until the initial plan of care is completed.
5. Send the 3160, Medicaid confirmation page (or put on 3160 comments), Provisional Plan of Care (PPOC)
to KDADS.SED @ks.gov. The ICE packet, CAFAS, CBCL, Strengths and Needs assessment are to be
uploaded to KAMIS (see instructions for uploading to KAMIS). Clinical eligibility by KDADS should be
determined within 5 days. Financial eligibility should be determined within 10 days by KDHE. KDHE will
forward the Approved or Denied 3160 and the PPOC to the assigned MCO, CMHC, and KDADS after
signing the 3160 and send out the NOAs to the family.
6. If Exception Request is required, submit an eligibility exception request for the youth's age (Attachment B
& C) to the KDADS SED Waiver Program Manager if the child/youth is younger than 4 or between 18 and
21 years of age. The date of the eligibility exception request approval becomes the clinical eligibility date.
Follow instructions on Exception Request forms for uploading required eligibility documents to KAMIS. Email
a 3160, PPOC, and Medicaid Application Confirmation number (or put confirmation page on 3160
comments) to KDADS SED Waiver Program Manager to sign, if approved. KDADS will then send these
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documents to KDHE/ /MCO Mailboxes with items in #7. KDHE will approve financial eligibility and notify
CMHC, MCO, KDADS, and send NOA to family.
7. Once financial eligibility has been determined and an MCO assigned, the MCO will complete the and
Person-Centered Service Plan and Personal Interest Inventory within 14 days in collaboration with the
CMHC.
8. CMHC will coordinate with the child/youth/family and MCO to schedule an initial wraparound to develop the
plan of care.
9. If a child on the SED Waiver receives in patient services in a Psychiatric Residential Treatment Facility,
Qualified Residential Treatment Program, or Youth Residential Center for longer than 30 days, they must
re-apply for SED Waiver services.
Figure 1: Process Map: Steps for Determining SED Waiver Eligibility
Exceptions to SED Waiver Criteria
Exceptions to allow a child/youth to access the SED Waiver outside of the eligibility criteria can be requested for:
1. CBCL subscale does not meet the threshold, but falls between 63 and 69 in one category;
2. CBCL subscale does not meet the threshold, but falls between 63 and 69 in one category
3. Children under age 4 who have a need for SED Waiver services;
4. Children who are over the age 18 and have a continuing need for SED Waiver services, before they reach
their 19th birthday;
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5. Children that are age 18 and need initial access to SED Waiver services
Steps for requesting Initial Exception to SED Wavier
Criteria
1. Within 5 business days, CMHC will complete an SED Waiver exception request and upload required
documentation (ICE Form, CAFAS, CBCL, exception request form) into KAMIS (will have to create a client).
2. Fill out a 3160 and email to [email protected] to sign/approve the exception. Include PPOC and Medicaid
Application confirmation page (or indicate in comments on 3160).
3. KDADS SED Waiver Program Manager will have 5 business days to process the exception request.
4. KDADS SED Waiver Program Manager will send signed 3160 form, PPOC, and Medicaid Application
confirmation number to KDHE for financial eligibility. KDHE will send completed 3160 and PPOC to KDADS,
CMHC and MCO. KDHE will send NOA to family or waiver participant.
Figure 2: Process Map: Exceptions
Notice of Action Requirements
A document sent to the waiver participant/s parent/guardian by the State notifying Waiver Participants of changes
or eligibility. MCO send out NOA when there is an adverse action to the participant’s service plan. (60+3 days) For
a closure the MCO will send a 3161 to KDADS. The KDADS Program Manager will review sign the 3161 send to
KDHE and the NOA will be sent as appropriate by KDHE.
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Figure 3: SED Waiver 3160 Flowchart
Financial Eligibility
Financial eligibility for the SED Waiver is determined by the KanCare HCBS application. A parent/guardian or youth
age 18 or older must complete and submit the required application online. CMHCs can assist families in completing
the online application. Only the child/youth income/assets are considered when determining financial eligibility. If
the parent/guardian requests to have prior medical expenses reviewed, the parent/guardian/youth should check the
"prior medical'' box on the application.
If the parent/guardian/youth are completing a new KanCare HCBS application online the CMHC should be given
and retain copy of the confirmation of the application.
Youth who have turned 18 need to complete a new KanCare application prior to turning age 19 if they are going to
request to continue to receive SED Waiver services.
Client Obligation
There are instances when a child/youth's income may exceed the income standard for Medicaid. In such
cases, a client obligation amount is calculated by KDHE eligibility staff. The client obligation is a monthly
amount the individual/family is responsible for paying toward his or her cost of waiver services each
month. The monthly client obligation must not exceed the monthly cost for the six waiver services (Parent
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Support and Training, Wraparound Facilitation, Short Term Respite Care, Independent Living/Skills
Building, Attendant Care, and Professional Resource Family Care) the waiver participant receives. If the
monthly client-obligation exceeds the monthly cost of the six waiver specific services, the Waiver
participant is no longer eligible for the SED Waiver.
Kansas Medical Assistance Plan (KMAP) Website
The Kansas Medical Assistance Program (KMAP) website provides information to Medicaid beneficiaries and
providers. Authorized providers can access the secure website to inquire about claims and verify a waiver
participant's eligibility for the SED Waiver. The waiver participant's eligibility screen lists the Program (e.g.: HCBS
Serious Emotional Disturbance), Effective Date, and End Date in the eligibility section and the client obligation.
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SED Waiver Services The six specific services provided under the SED waiver are described on the following pages.
Parent Support and Training
Parent Support and Training is designed to provide families of children who have been identified to have a serious
emotional disturbance and in need or at risk of more intensive level of care such as inpatient psychiatric hospital,
psychiatric residential treatment facility (PRTF), or crisis. Services may provide the training and support necessary
to ensure engagement and active participation of the family in the treatment planning process with the ongoing in
implementation and reinforcements of skills learned throughout the treatment process. Training is provided to family
members to increase their ability to provide a safe and supportive environment in the home and community for the
participant. Parent Support and Training can be provided anywhere in the community that is agreeable to the
individual. For the purposes of this service, “family” is defined as the persons who live with or provide care to a
person served on the waiver, and may include parent, spouse, children, relatives, grandparents, or foster parents.
Services may be provided individually or in a group setting.
C om p on e n t s o f P a r e n t Su p p o r t a n d T ra i n i n g 1. Support, coaching and training provided to the family members to increase their ability to provide as safe
and supportive environment in the home and community for the member.
2. Helping the families identify and use healthy coping strategies to decrease caregiver strain, improve
relationships with family, peers and community members and increase social supports.
3. Assisting the family in the acquisition of knowledge and skills necessary to understand and address the
specific needs of the waiver participant in relation to their mental illness and treatment;
4. Development and enhancement of the families specific problem-solving skills, coping mechanisms,
strategies for the waiver participant's symptom/behavior management;
5. Assist the family in understanding the various requirements of the waiver, such as the crisis plan and plan
of care process
6. Educational information and understanding on the participant’s medications or diagnoses; interpreting
choice offered by service providers; and assisting with the understanding policies, procedures and
regulations that impact the participant with mental illness while living in the community; provide information
on supportive resources in the community;
7. Services must be intended to achieve the goals and or objectives identified in the participant’s individualized
plan of care.
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L i m i t a t i o n s a n d E x c l u s i on s 1. There are no limits; provider managed
2. Service requires prior authorization
3. 1 FTE to 10 participants / families is maximum group size.
4. Parent Support and Training will not duplicate any other Medicaid State Plan service or other services
otherwise available to the recipient at no cost.
5. Operationally, individuals receiving Parents Support Training do not simultaneously receive Professional
Resource Family Care
A d d i t i on a l Se rv i c e C r i t e r i a 1. Services provided to children and youth must include communication and coordination with the family
and/or legal guardian. Coordination with other child serving systems should occur as needed to achieve the
treatment goals, all coordination must be documented in the youth's medical record. 2. Providers must receive ongoing and regular clinical supervision by a person meeting the qualifications of a
Qualified Mental Health Professional (QMHP) and supervision shall be available at all times.
Provider Qualifications
• High School diploma or equivalent.
• Minimum 21 years of age.
• Preference is given to parents or
caregivers of children with SED
• Completion of Parent Support training
according to a curriculum approved by
KDADS within six months of hire.
• Pass KBI, Department of Children and
Families child abuse check, adult abuse
registry checks and motor vehicle
screens.
Allowed Modes of Delivery
• Family
• Group
• On-site
• Off-site
• Telephonic
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Independent Living/Skills Building
Independent Living/Skills Building services are designed to assist waiver participants who are or will be transitioning
to adulthood with support in acquiring, retaining, and improving self-help, socialization, and adaptive skills necessary
to be successful in the domains of employment, housing, education, and community life and to reside successfully
in home and community settings.
C om p on e n t s o f I n d e p e n d e n t L i v i n g / S k i l l s B u i l d i n g 1. Independent Living/Skills Building activities are provided in partnership with waiver participants to help him
or her arrange for the services needed to become employed, find transportation, housing, and continue
their education.
2. Services are individualized according to each waiver participant's strengths, interests, skills, goals as
specified in the Plan of Care.
3. It would be expected that Independent Living/ Skills Building activities take place in the community.
4. This service can be utilized.to train and cue normal activities of daily living and instrumental activities of
daily living.
5. Housekeeping, homemaking (shopping, childcare, and laundry services), or basic services solely for the
convenience of a waiver participant receiving independent living / skills building are not covered.
6. The following are examples of appropriate community settings rather than an all-inclusive list:
a. a grocery store to shop for food,
b. a clothing store to teach the participant what type of clothing is appropriate for interviews,
c. an unemployment office to assist in seeking jobs or assist the participant in completing applications
for jobs,
d. apartment complexes to seek out housing opportunities, and
e. laundromats to teach the participant how to wash clothing.
7. Other appropriate activities can be provided in other community setting as identified through the Plan of
Care process.
8. Transportation is provided between the participant's place of residence and other services sites or places
in the community and the cost of transportation is included in the rate paid to providers of this service
L i m i t a t i o n s / E x c l u s i on s 1. Service requires prior authorization
2. No limits; provider managed
Provider Qualifications
• High school diploma or equivalent.
• Minimum 21 years of age.
• Pass KBI, DCF child abuse check, adult
abuse registry and motor vehicle
screens.
• Completion of an approved training in
the skills area(s) need by the
transitioning youth
• according to a curriculum approved by
KDADS prior to providing the service.
Allowed Modes of Delivery
• Individual
• On-site
• Off-site
• Independent Living / Skills Building will
not duplicate any other Medicaid State
Plan service or other services otherwise
available to recipient at no cost.
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A d d i t i on a l Se rv i c e C r i t e r i a 1. Services provided to children and youth must include communication and coordination with the family
and/or legal guardian.
2. Coordination with other child serving systems should occur as needed to achieve the treatment goals.
3. All coordination must be documented in the youth's medical record.
4. Providers must receive ongoing and regular clinical supervision by a person meeting the qualifications of a
Qualified Mental Health Professional (QMHP) and supervision shall be available at all times.
Short Term Respite Care
Short Term Respite Care provides temporary direct care and supervision for the participant. The primary purpose
is to provide relief to families/caregivers of a participant with serious emotional disturbances in or outside the home:
C om p on e n t s o f Sh o r t - T e rm R e s p i t e C a re 1. The service is designed to help meet the needs of the primary caregiver, as well as the identified participant.
2. Normal activities of daily living are considered content of the service when providing respite care. These
include:
a. support in the home, after school, or at night,
b. transportation to and from school, medical appointments, or other community-based activities,
c. and/or any combination of the above.
3. Short Term Respite Care can be provided in an individual's home or place of residence or provided in other
community settings.
4. Other community settings include:
a. Licensed Family Foster Home.
b. Licensed Crisis House
c. Licensed Emergency Shelter
d. Out-of-Home Crisis Stabilization House/Unit/Bed.
e. Not covered- see Limitations
5. The cost of transportation is included in the rate paid to providers of these services.
6. Short Term Respite care can be provided in a group setting as long as the safety of the waiver participant
is maintained.
7. Overnight setting outside the family or relative’s home, the home or facility must meet the applicable DCF
licensure requirements.
Provider Qualifications
• High School diploma or equivalent.
• Minimum 21 years of age.
• Completion of respite training according to
the curriculum approved by KDADS prior to
providing the service.
• Pass KBI, DCF child abuse check, adult
• Individual or group
Allowed Modes of Delivery
• On Site
• Off Site
• Abuse registry and motor vehicle screens.
• Certification in: First Aid, CPR, Crisis
Prevention/ Management (example: Crisis
Prevention Institute (CPI, Mandt, etc.)
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L i m i t a t i o n s / E x c l u s i on s 1. Service requires prior- authorization may not be provided simultaneously with Professional Resource Family
Care services. The service being provided at midnight is the service to be billed that day.
2. Short Term Respite Care may not be provided simultaneously with Professional Resource Family Care
services. The service being provided at midnight is the service to be billed that day.
3. Short Term Respite Care is not available to participants in foster care because that service is available
through foster care contracts. It can be provided to participants who are in state custody who are living at
home.
4. Short Term Respite Care will not duplicate any other Medicaid State Plan service or other services
otherwise available to recipient at no cost.
5. Other community settings which involve alternative financial coverage for placement including Licensed
Foster Homes, Licensed Emergency Shelters, Out of home Crisis Stabilizations houses/units/beds, or
Institutions of Mental Diseases (IMD).
6. Service cannot be provided in a Youth Residential Center (YRC 1 or 2) or Qualified Residential Treatment
Program (QRTP).
7. Federal Financial Participation is not claimed for the cost of room and board.
A d d i t i on a l Se rv i c e C r i t e r i a 1. Services provided to children and youth must include communication and coordination with the family
and/or legal guardian. Coordination with other child serving systems should occur as needed to achieve the
treatment goals. All coordination must be documented in the youth's medical record.
2. Providers must receive ongoing and regular clinical supervision by a person meeting the qualifications of a
Qualified Mental Health Professional (QMHP) and supervision shall be available at all times.
Wraparound Facilitation
Wraparound Facilitation is provided in addition to targeted case management to address the unique needs of a
participant living in the community. The function of the wraparound facilitator is to form the wraparound team
consisting of the participant's family, extended family, and other community members involved with the participant's
daily life, and the chosen/assigned MCO for the purpose of producing a community-based, individualized Plan of
Care.
C om p on e n t s o f W ra p a r ou n d F a c i l i t a t i on 1. The wraparound facilitator guides the Plan of Care development process of the team to assure that waiver
rules are followed but the WAF no longer create the plan of care. Development was moved to MCO to work
together with CMHC’s to create The Person-Centered Service Plan. The MCO care coordinator is
responsible for implementing changes to The Service Plan.
2. The wraparound facilitator is responsible for reassembling the team when subsequent Service Plan review
and revision are needed, at minimum on a yearly basis or more frequently when changes in the participant’s
circumstances warrant changes in the Service Plan..
3. The wraparound facilitator will emphasize building collaboration and ongoing coordination among the
family, caretakers, service providers, MCO care coordinator and other formal and informal community
resources identified by the family and promote flexibility to ensure that appropriate and effective service
delivery to the waiver participant and family/caregivers.
17
4. Facilitators will be certified after completion of specialized training in the wraparound philosophy, waiver
rules and processes, waiver/grant eligibility and associated paperwork, structure of the waiver participant
and family team, and meeting facilitation.
L i m i t a t i o n s / E x c l u s i on s 1. Wraparound facilitation cannot duplicate any services provided by target case management services.
2. The Targeted Case Management (TCM) and Wraparound Facilitator (WAF) cannot be the same person,
however the TCM for one participant may be a WAF for a different person.
A d d i t i on a l Se rv i c e C r i t e r i a 1. Services provided to children and youth must include communication and coordination with the family
and/or legal guardian. Coordination with other child serving system should occur as needed to achieve the
treatment goals. All coordination must be documented in the waiver participant's medical record.
2. Providers must receive ongoing and regular clinical supervision by a person meeting the qualifications of a
Qualified Mental Health Professional (QMHP) and supervision shall be available at all times.
Professional Resource Family Care
Professional Resource Family Care is intended to provide intensive supportive resources for the waiver participant
and family. This service offers intensive family-based support for the waiver participant's family through the utilization
of a co-parenting approach provided to the waiver participant in a surrogate family setting.
C om p on e n t s o f P ro f e s s i on a l R e s ou rc e F a m i l y C a re 1. The goal is to support the waiver participant and family in ways that will address current acute and/or chronic
mental health needs and coordinate a successful return to the family setting at the earliest possible time.
2. During the time the professional resource family is supporting the waiver participant, there is regular contact
with the family to prepare for the participant's return and ongoing needs as part of the family.
3. It is expected that the waiver participant, family and the professional resource family are integral members
of the participant's individual treatment team.
Provider Qualifications • Minimum of BA/BS degree or be
equivalently qualified by work experience or
a combination of work experience in the
human services field and education with
one year of experience· substituting for one
year of education.
• Completion of Wraparound Facilitation
according to a curriculum approved by
KDADS within one year of hire (6 months
preferred).
• Pass KBI, DCF child abuse check, adult
abuse registry and motor vehicle screens.
Allowed Modes of Delivery
• Individual
• On-site
• Off-site
• Service requires prior authorization
• Wraparound Facilitation
• Provided in addition to targeted case
management to address the unique needs
of waiver participants living in the
community and does not duplicate any-
other Medicaid State Plan service or
services otherwise available to the waiver
participant at no cost.
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4. Transportation is provided between the waiver participant's place of residence and other services sites or
places in the community; and the cost of transportation is included in the rate paid to providers of these
services.
L i m i t a t i o n s / E x c l u s i on s 1. Service requires prior authorization.
2. Professional Resource Family Care may not be provided simultaneously with Short Term Respite Care
services.
3. Professional Resource Family Care is not available to participants in out of home placement because that
service is available through foster care contract (Therapeutic Foster Care).
4. FFP is not claimed for the cost of room and board.
5. Professional Resource Family Care does not duplicate any other Medicaid State Plan service or service
otherwise available to the waiver participant at no cost.
A d d i t i on a l Se rv i c e C r i t e r i a 1. Services provided to children and youth must include communication and coordination with the family
and/or legal guardian. Coordination with other child serving systems should occur as needed to achieve the
treatment goals. All coordination must be documented in the waiver participant's medical record.
2. Providers must receive ongoing and regular clinical supervision by a person meeting the qualifications of a
Qualified Mental Health Professional (QMHP) and supervision shall be available at all times.
Attendant Care [§1915(c)] / Personal Care (waiver
language)
The service enables the waiver participant to accomplish tasks or engage in activities that they would normally do
themselves if they did not have a mental illness. Assistance is in the form of direct support, supervision and/or cuing
so that participant performs task by him/herself. Such assistance most often relates to performance of Activities of
Daily Living and Instrumental Activities for Daily Living and includes assistance with maintaining daily routines and/or
engaging in activities critical to residing in their home and community.
Provider Qualifications
• High School diploma or equivalent.
• Minimum 21 years of age.
• Completion of state approved training
according to a curriculum approved by
KDADS prior to providing the service.
• Pass KBI, DCF child abuse check, adult
abuse registry, and motor vehicle screens.
Family residence licensed by Department of
Children and Families.
• Certification in First Aid, CPR, Crisis
Prevention/Management (example: CPI,
Mandt, etc.)
Allowed Modes of Delivery
• Individual
• On-Site
• Off-Site
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C om p on e n t s o f A t t e n d a n t C a re 1. Services should generally occur in community locations where the waiver participant lives, works, attends
school, and/or socializes.
2. Services must be recommended by a wraparound team, are subject to prior approval, and must be intended
to achieve the goals or objectives identified in youth’s Person-Centered Service Plan.
3. Transportation is provided between the participant's place of residence and other services sites or places
in the community, and the cost of transportation is included in the rate paid to providers of this services.
KanCare MCO’s will be responsible for all other transportation needs for the waiver participant.
L i m i t a t i o n s / E x c l u s i on s 1. Services must be prior authorized. Attendant Care has no unit limit.
2. Services provided at a work site must not be job tasks oriented.
3. Services provided in an educational setting must not be educational in purpose or duplicate services
required to be provided by the educational institution.
4. Services furnished to a waiver participant who is an inpatient or resident of a hospital, nursing facility,
intermediate care facility for persons with intellectual or developmental disabilities, or institution for mental
disease are non-covered.
5. Attendant Care does not duplicate any other Medicaid State Plan Service or service otherwise available to
the waiver participant at no cost.
A d d i t i on a l Se rv i c e C r i t e r i a 1. Services provided to children and youth must include communication and coordination with the family
and/or legal guardian. Coordination with other child serving systems should occur as needed to achieve the
treatment goals. All coordination must be documented in the waiver participant's medical record.
2. Providers must receive ongoing and regular clinical supervision by a person meeting the qualifications of a
Qualified Mental Health Professional (QMHP) and supervision shall be available at all times.
One Waiver Service Monthly Requirement
Per waiver language:
Reasonable Indication of Need for Services: In order for an individual to be determined to need waiver services,
an individual must require:
1. the provision of at least one waiver, as documented in the service plan, AND
2. the provision of waiver services at least monthly or, if the need for services is less than monthly, the
participant requires regular monthly monitoring which must be documented in the service plan.
Provider Qualifications
• High school diploma or equivalent.
• Minimum 18 years of age and at least 3
years older than the youth.
• Completion of state approved training
according to the curriculum approved by
KDADS prior to providing the service.
• Pass KBI, DCF child abuse check, adult
abuse registry, and motor vehicle screens.
Allowed Modes of Delivery
• Individual
• On-site
• Off-site
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The SED waiver must be closed when a waiver service has not been provided to a waiver participant for
two consecutive months.
KDHE, the MCO’s, and the CMHC’s review data to determine if waiver services are being received monthly. If
members are identified, outreach will occur to identify any barriers to receiving services. The CMHC’s must
document their attempts to provide a service at least once a month and their attempts to reduce barriers to
receiving services.
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Person-Centered Service Plan
Person Centered Service Plans for SED Waiver participants must be developed by a wraparound team.
Wrap-around team
The Wrap Around Facilitator is responsible for facilitating the team meeting and coordinating participation and
information. The MCO is a participant in the meeting and responsible for the creation of the person-centered service
plan.
The MCO care coordinators will work with the Community Mental Health Centers (CMHC’s) to create and approve
plans of care for waiver clients utilizing waiver services. All changes to the Person-Centered Service Plan will be
done by the MCO care coordinator.
The WAF has the responsibility to form the wraparound team consisting of participant’s family, extended family, and
other community members involved with the participant’s daily life to provide information to assist in the MCO
development of the Person-Centered Service Plan. The WAF continues to be responsible for reassembling the team
when subsequent Person Centered Service Plan review and revision is needed, at minimum every 90 days to review
the Person Centered Service Plan and more frequently when changes in the participant’s circumstances warrant
changes in the Person Centered Service Plan.
The purpose of the Person-Centered Service Plan is
to:
1. Assess the waiver participant's individual strengths and needs.
2. Develop goals and objectives based on the waiver participant's identified strengths and needs.
3. Specify the services needed to accomplish those goals and objectives
4. The Person-Centered Service Plan developed by the wrap-around team, will Identify providers (name of
CMHC) for specific services in amount duration and scope.
Chapter
3
22
Essential elements to the Person-Centered Service
Plan document include:
1. Identifying information including name, beneficiary ID, DOB, address/phone, parent/guardian name, contact
information, and diagnosis
2. Participation list: Including level of involvement, relationship to the waiver participant, and phone number.
The participation list should include only those participants of the treatment team that participated in that
particular review of the Person-Centered Service Plan.
3. Strengths and Needs Assessment: Each strength and need in each domain must be addressed. For
example, if there are no legal issues, list "no legal issues" as strength in that domain rather than ''NIA".
4. Goals and Objectives: The goals and objectives should be measurable and reflect the strengths and needs
of the waiver participant.
5. Crisis Plan: The crisis plan should be thorough, including action steps, and person(s) responsible for each
potential crisis. Each crisis plan must have triggers and action steps for crisis aversion, crisis 'resolution,
and post-crisis follow-up.
6. Services indicated: services indicated should outline specific services in amount, duration, and scope.
7. Signatures: If 5 or older, waiver participants should sign their Person-Centered Service Plan, or
documentation should exist to explain the absence of a signature. Such documentation may include a
progress note, or a note on the signature line indicating the reason for a lack of signature. All participants,
including the legal guardian shall sign and date the Person-Centered Service Plan document signature
page. The person signing as legal guardian needs to have legal authority to do so. The approved mental
health professional is the QMHP.
Natural supports
Natural supports to the waiver child/youth and his/her family-are highly encouraged to participate when forming the
wraparound team and developing the Person Centered Service Plan. Natural supports can include but are not
limited to immediate and extended members, members of the community who provide support to the waiver
participant and/or his or her family, and friends.
Goals and Objectives
A key factor in developing an effective Person-Centered Service Plan is to develop clear, measurable goals
and objectives. The strengths and needs assessment provide the foundation for developing goals and objectives of
the Person-Centered Service Plan.
Strengths and Needs Assessment
The following is a list of possible strengths that can be included in the strengths/needs assessment. It is important
to note that all domains must be addressed in the strength/needs assessment.
1. Able to verbalize needs
2. Usually is prompt and on time
3. Belonging to several clubs
4. Maintains positive work attitude
5. Uses conflict resolution skills
6. Meets personal goals
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7. Passing all classes at school
8. Tolerant when frustrated
9. Remedies for difficulties
10. Able to meet new/appropriate friends
11. Organizes well
12. Enjoys community service
13. Responds well to incentives
14. Obtained driver's license
15. Gives/receives feedback
16. Works well with group of peers
17. Sensitive to other cultures
18. in his/her church
19. Has a job
20. Enjoys teamwork/is a team player
21. Likes to help others
22. Applies leadership skills
23. Wants to accept responsibility
24. Behavior appropriate to situation
25. Complete homework
26. Enjoys leisure activities
27. Able to use computer
28. Handles disappointment without outbursts
29. Uses negotiation skills
30. Enjoys organized games
31. Likes to participate at school
32. Enjoys field trips
33. Attends support group
34. Provides homework help to siblings
35. Learns· from experiences
36. Uses anger management skills
37. Asks permission
38. Respectful toward adults
39. Able to complete chores
40. Is able to express love for family
41. Able to follow instructions
42. Social skills: appropriate conversation,
respect,
43. Saves money for special purchases
44. Appropriate language, interaction with job
45. Able to keep monthly schedule
46. Interviewing/resume development skills
47. Attends school regularly
48. Able to dress appropriately
Crisis Plan
A crisis plan is developed in conjunction with the team. Each component of the Crisis Plan must be completed,
including action steps, and person(s) responsible for each
Potential crisis. Each crisis plan must have triggers and action steps for crisis aversion, crisis resolution, and post-
crisis follow-up. All team members need access to the crisis plan.
Below are some guidelines in developing effective
crisis plans.
E f f e c t i v e c r i s i s p l a n s : 1. Are developed before a crisis occurs
2. Anticipate a crisis based on past behavior
3. Plan to meet the needs of the whole family
4. Address training needs for behavior management for the parent, so that management can happen as
effectively in the home as well by the MH/BH team at the CMHC.
5. A crisis is a process with a beginning, middle and end. Plan a response with a beginning, middle, and end.
6. A crisis plan is written and reviewed regularly.
7. Crisis plans are modified as needed based on the changing needs of the family and waiver participant.
8. Establish capacity for 24-hour crisis response
9. Establish a clear measure of when the crisis is over
24
10. Schedule a wraparound team meeting within three days following a crisis.
Dual Diagnosis Children and the IDD waiver: please note that any crisis access requests
to the IDD waiver must demonstrate that all community resources have been exhausted,
including those provided by the SED waiver, if the child is on the SED waiver at the time
of an IDD crisis request.
Person-Centered Service Plan: Reviews
The Person-Centered Service Plan must be reviewed, and wraparound facilitation must be provided at least every
90 calendar days with the waiver participant and/or parent/guardian.
1. This cycle may not correspond exactly with your 90 day treatment plan reviews for Medicaid. It is best
practice for the Person-Centered Service Plan and treatment plan reviews to happen at the same time.
2. The date you review the Person-Centered Service Plan with the waiver participant and/or parent/guardian
restarts the 90-day review cycle.
Person Centered Service Plan review: P a rt i c i p a n t s
Participants must include the child/youth (if the child/youth doesn’t participate the reason for their absence should
be documented), parent/legal guardian, wrap around facilitator, MCO (for continuity of care and service delivery to
the family, the meeting may proceed if delaying would cause a delay in service delivery).
It is best practice to also include all wrap around team members. If they are not able to participate, their input should
be obtained prior to the meeting.
Person Centered Service Plan: R e v i e w & S i g n a t u re s The CMHC will follow [regulation] requirements regarding review of the Person-Centered Service Plan by a QMHP.
The child/youth (if over age 5) and their legal guardian must sign the Person-Centered Service Plan within 30
calendar days of completion.
If a private provider is furnishing outpatient mental health services to the waiver participant, it would be ideal for the
private provider to be a member of the wraparound team. If this is not possible, -the wraparound facilitator should
consult with the private provider on a quarterly basis to review the treatment plan and for coordination of care. This
coordination/consultation can be accomplished through phone calls, encrypted e-mails, and/or letters.
After every Person-Centered Service Plan review, the updated service authorization will be communicated to the
provider and family by the MCO within 14 calendar days
Annual Eligibility Reviews
Eligibility for continued SED Waiver services must be reviewed annual If this is the first annual review, this review
occurs within 364 days of the child/youth’s initial financial eligibility date. All subsequent reviews are due within 364
Note:
25
days of the last Annual Level of Care review form (Attachment E) document. The requirements of the SED Waiver
Annual Level of Care include:
1. The annual eligibility evaluation is completed by a QMHP and documented on the SED Waiver Annual
Evaluation of Level of Care form (Attachment E) and must reference the previous six months.
2. If the youth has reached their 18th birthday (and each subsequent review thereafter) at the annual review
time, the youth must receive approval to continue on the SED Waiver by the KDADS SED Waiver Program
Manager. The exception process is outlined on page 8.
3. Persons who have reached their 22nd birthday are no longer eligible for the SED Waiver.
The QMHP is responsible for determining the Annual Level of Care eligibility through collaboration with child/youth,
guardian, and wraparound support team. The Annual Level of Care eligibility must occur prior to or in conjunction
with the Annual Plan of Care/Service Plan development.
Annual Wraparound Meeting:
The annual wraparound team meeting is scheduled by WAF at the last quarterly review meeting. Scheduling occurs
in collaboration with the family and MCO representative at an agreed upon time and date that works best for the
family. The child/family meeting preferences for time and location are important and should be honored as much as
possible. The review of the CMHC Plan of Care and MCO Service Plan should be conducted face to face with the
full wraparound team. If the child/youth continues to meet clinical eligibility at the annual review the MCO will
complete Service Plan and send completed copy to family/youth and CMHC. MCO will send SED Waiver service
authorization approval to CMHC within 14 business days.If the child/youth no longer meets clinical eligibility at the
annual review, the annual meeting will be used to create a plan for transitioning the child/youth from the Waiver.
If child/youth continues to meet clinical eligibility at Annual Review:
1. CMHC will upload the Annual Level of Care form to KAMIS.
2. WAF will coordinate scheduling of next quarterly review. WAF will make all efforts to remind family of
previously scheduled review meetings.
If child/youth no longer meets clinical eligibility at Annual Review:
1. A plan is developed, and closure date of the SED Waiver is communicated to the family.
2. A 3161 is completed and sent to the SED Program Manager along with (form indicating reason for loss of
eligibility).SED Program Manager reviews and signs and sends to KDHE.KDHE reviews and closes case and
sends Notice of Action and completes 3161 and send back to CMHC, MCO, SED Program Manager.
Special directions for youth that are 18 years of age or older at the time of the Annual Review:
Refer to instructions on Section C. on Annual Level of Care form.
26
Transfers
If a waiver participant is transferring services to a different CMHC, the waiver case should be transferred to ensure
continuity of care. It is important that the MCO, transferring and receiving CMHCs coordinate care during the
transfer to ensure the one Waiver service per month requirement is maintained. Existing services remain in place
until the child moves and new services are established to assure services are seamless. MCO will coordinate with
both CMHCs transfer date and start and end dates of service authorizations accordingly. It is the family's choice to
transfer to a CMHC outside of their catchment area, the family is responsible to travel to the CMHC outside their
catchment area for services. If SED Waiver eligibility is ended prior to intake/arrival at new CMHC.
A receiving center is-expected to begin providing waiver services immediately.
Responsibilities of the Transferring CMHC
The following are the steps the transferring center should take when a waiver participant is transferring services to
a new CMHC.
1. When the parent/guardian provides notification of their intent to move, the transferring center should ask
the family if they wish to receive HCBS services in their new location.
a. If the family wishes to continue services, the transferring CMHC will notify the care coordinator of
the MCO.
b. Obtain ROI to transferring CMHC. Ensure ROI identifies permission to transfer all SED Waiver
required transfer documents.
c. Assist family in coordinating SED Waiver transfer by assisting family in scheduling/completing
intake at Receiving CMHC.
2. If the family does not wish to continue services, the SED Waiver case must be closed. A 3161 is sent to the
KDHE designated mailbox and copy KDADS program manager.
3. Enter transfer into KAMIS or records department exchange between CMHCs.
a. Provide the following documentation:
i. Initial Clinical Eligibility form/Attachment D
ii. Approval letter for age and/or CBCL Exception, if applicable
iii. The most recent Annual Evaluation of Level of Care form
iv. The most recent Plan of Care
v. Initial Plan of Care
vi. Most recent Annual Plan of Care
vii. Qualifying CBCL and qualifying CAFAS (must include clinician signature [name &
credentials for electronic versions])
viii. Date of last waiver service
Chapter
4
27
4. If no contact from family/no new intake scheduled, contact MCO to assist and then Transferring CMHC to
Close if no contact within 30 days.
SED Waiver cases should always be transferred rather than closed. SED Waiver eligibility is portable; eligibility
moves as the participant moved. MCO will coordinate with both CMHCs transfer date and start and end dates of
service authorizations accordingly. MCO will authorize new CMHC with existing Person Centered Service Plan
service authorizations until new Person Centered Service Plan is built (up to 30 days from intake).
1. Contact KDADS Program Manager to resolve any questions regarding disputes/discrepancies and review
transfer status and direction for each CMHC.
2. Document the efforts taken to facilitate a smooth transfer.
Responsibilities of Receiving CMHC
The receiving CMHC assumes complete responsibility for maintaining the SED waiver for transferring waiver
participants. This includes maintaining records regarding the establishment and maintenance of initial clinical
eligibility. If the waiver participant and family does not follow through with completing an intake at Receiving CMHC,
the Transferring CMHC should close the waiver case.
If the receiving CMHC has received contact from SED Waiver participant and wishes to transfer SED Waiver to new
CMHC, please follow the steps below:
1. Obtain ROI and complete intake.
2. Notify MCO and transferring CMHC of scheduled or completed intake by email.
a. This must be done within 14 days of intake.
3. MCO will coordinate with both CMHCs transfer date and start and end dates of service authorizations
accordingly. MCO will authorize new CMHC with existing PERSON CENTERED SERVICE PLAN service
authorizations until new PERSON CENTERED SERVICE PLAN is built (up to 30 days from intake)
a. This must be done within 30 days of intake
4. MCO and CMHC will coordinate with family to hold a new POC/PERSON CENTERED SERVICE PLAN
meeting.
a. Send POC to the MCO
b. This must be done within 30 days.
5. Contact KDADS Program Manager to resolve any questions regarding disputes/discrepancies and review
transfer status and direction for each CMHC.
6. Document the efforts taken to facilitate a smooth transfer.
When people move without notice
There are instances when a waiver participant and his or her family moves without advance notice and presents at
the receiving CMHC without prior notice. Coordination with the former CMHC should occur in these cases. The
following are the steps the new center should take when a waiver participant is transferring services to a new CMHC
without prior notice.
1. Find waiver status using KMAP, Use KAMIS to confirm last CMHC. Contact previous CMHC to confirm
waiver eligibility once ROI is obtained.
2. Notify MCO care coordinator of the move for coordination of the transfer
3. Have the parent(s)/guardian(s) sign a Release of Information form for the former CMHC
4. Refer to Responsibilities of Transferring and Responsibilities of Receiving CMHC indicated above.
29
Figure 5: Process Map: When people move without notice
More Than One Center Providing Waiver Services to
a Waiver Participant
There are times when a waiver participant has a case open at more than one center. This might occur if a waiver
participant is visiting a parent or relative for the summer, or receiving services at a school in one location, and at
home in a different location.
For cases when the waiver participant is visiting a parent/relative for the summer, he or she must continue to receive
at least one waiver service each month in order for the waiver.to remain open. It is assumed that if a waiver
participant goes to another parent's/ relative or other person's home for the summer (out of that center's catchment
area) he or she continues to meet the eligibility requirements and will continue to need monthly services.
30
S t e p s f o r t h e t w o C M H C ' s s h a r i n g wa i v e r s e rv i c e p rov i s i on : 1. Thorough coordination must occur between the treatment team members and the MCOs. The Person-
Centered Service Plan developed by the MCO will address which CMHC will be assigned to provide the
identified services. Authorizations will be provided by the MCO to each CMHC describing the services they
will be providing for the member.
2. The primary CMHC is responsible for all required clinical 'eligibility and documentation supporting the
eligibility regarding the Waiver participant's SED Waiver.
3. The MCO will develop and maintain the Person-Centered Service Plan for the waiver participant
a. Each CMHC's will maintain clear documentation of the services being provided.
b. The Person-Centered Service Plan clearly documents the participation and involvement of the
treatment team/service care providers, and to include signatures from all participants.
c. The MCOs will send a current copy of the Person-Centered Service Plan to all CMHC addressed
on the Person-Centered Service Plan.
d. The Person-Centered Service Plan is also sent to the Waiver participant and their family
e. The collaborating CMHC is provided an authorization for the services assigned to them on the
Person-Centered Service Plan.
SED Waiver Closure
The following are reasons for closing SED Waiver services:
1. Loss of clinical eligibility: A waiver participant loses clinical eligibility for waiver services at any point where
he or she no longer meets the Level of Care standard for the waiver. Loss of clinical eligibility may occur at
the annual review or earlier if there is evidence the waiver participant is no longer at risk of inpatient
psychiatric hospitalization.
2. Change in medical condition: The presence of a medical condition that prevents participation in, or the
appropriateness of, community-based mental health services. Such a change in the level of medical care
must be documented by the waiver participant’s physician. A Notice of Action may be sent the same day
as closure.
3. A written and signed statement indicating family/youth choice: Circumstances around such a choice will be
carefully reviewed with the parent or guardian by the SED Waiver service provider, and documented in the
clinical record.
4. Maximum age: A youth who reaches their 22nd birthday is no longer eligible for SED Waiver services.
5. Probable fraud and/or abuse: The agency has facts indicating that action should be taken because of
probable fraud by the waiver participant, and the facts have been verified, if possible, through secondary
sources.
6. Death of beneficiary
7. When a waiver participant moves out of Kansas, he or she is no longer eligible for SED Waiver services.
8. Institutional Placement: Medicaid rules state that if a waiver participant is admitted to any inpatient or
institutional setting for more than 30 days, the waiver must be closed as the waiver participant is no longer
considered to be living in a community setting and is therefore ineligible for home and community based
services.
9. Not receiving one waiver service a month: A Waiver participant must have at least one waiver service a
month to stay on the SED Waiver.
10. Loss of financial eligibility: The waiver participant and/or his or her family does not return the annual financial
review or not cooperating with the financial eligibility process.
11. Beneficiary’s address unknown: The waiver participant’s whereabouts are unknown and the post office
returns agency mail directed to him or her indicating no forwarding address.
31
12. Lack of Cooperation in the last 30 days: This reason should only be used if the following criteria have been
met and are documented in the Waiver participant’s medical record:
13. Efforts to engage the waiver participant in services and the treatment planning process are not successful.
14. Efforts to identify possible barriers to treatment. These barriers could include location of services, time of
services, interpersonal issues with staff, lack of progress in treatment, and barriers related to the family’s
mental health or substance related issues. Any barriers to treatment must be explored and addressed with
the waiver participant and/or his or her family before closure of the waiver can occur.
15. Documented outreach must occur multiple times with different kinds of outreach, including visits to the
home, by letter, by email if applicable, and telephonically.
In the event of SED Waiver closure, the State will send a letter to the waiver participant family/youth. The CMHC will
send a 3161 via email to the KDHE designated mailbox. KDHE will send the NOA to the family with a 33 Day appeal
time. KDHE will review and sign the 3161 and send back to the KDADS program manager, the MCO, and the CMHC.
The MCO will ensure SED Waiver service authorizations are active for a full 33 days in the event the family appeals
closure decision. If family does appeal, CMHC must reestablish SED Waiver services and provide services as
authorized on last Service Plan, until final outcome of appeal process is determined. CMHC may also choose to
utilize this time period as a transitional phase off SED Waiver services. Once 33 days has lapsed and no appeal has
been made by the family, KDHE will notify the MCO, KDADS and the CMHC’s that the case is closed via the 3161
process.
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Prohibited Restrictive Interventions and the
Use of Restraint
Kansas statute, regulation and HCBS SED Waiver policy prohibit the following:
1. Chemical Restraints - medication used as restraints means any medication that:
a. is administered to manage a waiver participants behavior in a way that reduces the safety risk to
the waiver participant or others; and
b. has the temporary effect of restricting the resident’s freedom of movement; or
c. is not standard treatment for the waiver participant's medical or psychiatric condition.
2. Mechanical restraints- means any device attached or adjacent to the waiver participant's body that he or
she cannot easily remove which restricts freedom of movement or normal access to his or her body.
3. Seclusion - means the involuntary confinement of a waiver participant in an area where the waiver
participant is physically prevented from leaving as a means of controlling the person's behavior. Seclusion
is prohibited and differs from ‘time out’.
4. Physical Restraint - The use of physical restraint as a de-escalation technique and emergency behavioral
intervention is allowed only after all less restrictive interventions have been exhausted. Regulation governing
the use of Physical Restraint is found in K.A.R. 30-60-48. Physical restraint is only allowed as a de-escalation
technique and emergency behavioral intervention and includes:
a. Each staff waiver participant, volunteer, and contractor shall utilize only de-escalation techniques
or emergency behavioral interventions which that staff waiver participant, volunteer, or contractor
has been appropriately trained in or is professionally qualified to utilize and
b. No practice utilized shall be intended to humiliate, frighten, or physically harm a waiver participant.
c. No practice that becomes necessary to implement shall continue longer than necessary to resolve
the behavior at issue.
d. Physical restraint shall be used as a method of intervention only when all other methods of de-
escalation have failed· and only when necessary for the protection of that waiver participant or other
individuals.
e. Each instance of the utilization of a physical restraint shall be documented in the waiver participant's
clinical record required by K.A.R. 30-60-46 and reviewed by supervising staff and the CMHC's risk
management program required by K.A.R. 30-60-56.
f. Each instance in which the utilization of a de-escalation technique or emergency behavioral
intervention results in serious injury to the waiver participant shall be reported to KDADS central
office using the Adverse Incidents Report (AIR) application.
Chapter
5
33
Basis for use of restraint
Restraint techniques should only be used when all less restrictive methods of intervening have been exhausted and
are limited to situations in which there is serious, probable and imminent threat of bodily harm to self or others by a
person with the present ability to cause such harm. Physical restraints are not allowed for the sole purpose of
mediating destruction of property and must never be used as a punitive form of discipline or as a threat to
control or gain compliance of a person 's behavior. In all situations, less restrictive alternatives including, but not
limited to, positive behavior supports, constructive, non-physical de-escalation and re-structuring of the environment
shall be considered prior to initiating a physical restraint and used when feasible.
An HCBS SED Waiver provider shall:
1. Administer restraints only when needed to ensure the safety of the waiver participant and/or other
individuals in the immediate environment, (including but not limited to staff waiver participants, other waiver
participants, other individuals) and only when needed to prevent the continuation or renewal of an
emergency.
2. Use restraints only for the period of time necessary to accomplish its purpose and using no more force than
is necessary; and
3. Prioritize prevention of harm to the waiver participant in care if a restraint is administered.
Duties related to the use of restraint
When restraints are used, the CMHC shall ensure the following:
1. Direct care staff receive ongoing education, training, and review with a supervising Qualified Mental Health
Professional (QMHP) and/or an assembled team of interdisciplinary professionals (that must include a
supervising QMHP) to identify non-aversive techniques and strategies that aid the therapeutic process
through an expansion of the waiver participants own internalized ability to self-regulate behavior, the
progress of which is determined and evaluated by a QMHP familiar with the waiver participant and his or
her treatment history and is documented through established documentation procedures;
2. All physical restraints must be authorized by a QMHP prior to their use. Authorizations may be obtained
verbally, but this authorization must be documented in the waiver participant's clinical record by the QMHP
providing authorization.
3. Restraint· will only be administered by staff who have been trained to assure the physical safety of the waiver
participant;
4. A person administering the physical restraint must use only the amount of force necessary to stop
dangerous or violent actions of the waiver participant.
a. No restraint is administered in such a way that the waiver participant is prevented from breathing
or communicating.
a No restraint is administered in such a way that places excess pressure on the person’s chest, back,
or extremities;
5. Opportunities to have the restraint removed are provided to the waiver participant who indicates that he or
she is willing to cease violent or dangerous behavior;
6. When the restraint is no longer necessary to protect the waiver participant or ensure the safety of others,
the restraint must be removed. A physical restraint shall not continue for more than 15 minutes except when
essential to maintain the waiver participant's safety.
34
Staff training related to the use of restraint
All Community Mental Health Centers shall ensure that all SED Waiver providers who may utilize physical restraints
are trained according to a nationally recognized curriculum prior to providing SED Waiver services. Such a program
must emphasize the use of safe, non-harmful control and restraint techniques.
Training shall include:
1. Techniques to identify staff and waiver participant behaviors, events, and environmental factors that may
trigger emergency safety situations;
2. The use of nonphysical intervention skills, such as de-escalation, mediation conflict resolution, active
listening, and verbal and observational methods, to prevent emergency safety situations; and
3. The safe use of restraint, including the ability to recognize and respond to signs of physical distress in waiver
participants who are restrained.
4. Methods to explain the use of restraint to the parents or caregivers of the waiver participant; and
5. Documentation and notification procedures.
Individuals who are qualified by education, training and experience must provide staff training. Staff training must
include training exercises in which staff waiver participants successfully demonstrate in practice the techniques
they have learned for managing emergency safety situations. Staff must be trained and demonstrate competency
before participating in an emergency safety situation. These competency evaluations must be observed and
documented by the trainers.
The CMHC must document in the staff personnel records that the training and demonstration of competency were
successfully completed. Documentation must include the date training was completed and the name of persons
certifying the completion of training. All training programs and materials used by the CMHC must be available for
review by CMS, the Kansas Department of Health and Environment, and the Kansas Department for Aging and
Disability Services.
Documentation requirements related to the use of
restraint
At intake and annually, the CMHC must:
1. Inform the waiver participant and the waiver participant's parents or caregivers of the CMHC's policy
regarding the use of restraint during an emergency safety situation that may occur while the waiver
participant is in the program;
2. Communicate its restraint policy that includes the types of interventions and restraints commonly used in a
language that the waiver participant and the parents or caregivers of the waiver participant understand
(including American Sign Language, if appropriate) and when necessary, the CMHC must provide
interpreters or translators;
3. Obtain an acknowledgment, in writing, from the waiver participant, and the parents or caregivers of the
waiver participant that he or she has been informed of the CMHC's policy on the use of restraint during an
emergency safety situation. Staff must file this acknowledgment in the waiver participant's clinical record;
and
4. Provide a copy of the CMHC's policy to the waiver participant and the parents or caregivers of the waiver
participant.
35
Each instance of the utilization of a physical restraint shall be documented in the waiver participant's clinical record
required by K.A.R. 30-60-46 and reviewed by supervising staff and the CMHC's risk management program required
by K.A.R. 30-60-56, within 24 hours subsequent to a restraint being administered. Documentation of the physical
restraint shall include a justification why a less restrictive intervention was not utilized or failed to keep the waiver
participant safe. All incidents of restraint will be compiled by the CMHC risk manager and reported to KDADS central
office rising the Adverse Incidents Report (AIR) application.
Each instance in which the utilization of a de-escalation technique or emergency behavioral intervention results in
serious injury to the waiver participant shall be reported by the risk manager to KDADS central office using the
Adverse Incidents Report (AIR) application within 24 hours.
KDADS in collaboration with the CMHC risk manager will make a determination regarding a possible referral to child
protective services or law enforcement.
All contacts to the Adverse Incidents Report (AIR) application are documented in the state quality improvement
quarterly reports which are aggregated and tracked to determine if trends are present. If trends are present, KDADS
will develop a corrective action plan with the CMHC in question seeking to prevent utilization of seclusion.
Review of the use of restraint
Each CMHC shall ensure that a review process is established and conducted for each incident of restraint used.
The purpose of this review shall be to ascertain that appropriate procedures are followed and to minimize future
use of restraint. The review must be initiated within 72 hours of the utilization of the restraint.
The review shall include, but is not limited to:
1. Staff review of the incident;
2. Follow up communication with the waiver participant and the parents or caregivers of the waiver participant;
3. Review of the documentation to ensure use of alternative strategies; and
4. Recommendations for adjustments of procedures.
Each CMHC shall ensure that a general review process is established and conducted at least annually. The purpose
of the general review process is to ascertain that procedures are appropriate.
This review shall include but is not limited to:
1. Analysis of incident reports, including but not limited to procedures used during the restraint, preventative
or alternative techniques tried, documentation and follow-up training needs of staff;
2. Staff to client ratio, especially in regard to group settings; and
3. Environmental considerations, including physical space, noise levels, access to privacy necessary for staff
members to effectively utilize verbal techniques for re-establishing rapport, trust and communication with a
previously acting out waiver participant.
Waiver service providers self-report when the authorized use of restraints is discovered. A report is submitted via
an electronic database that is maintained by KDADS quality assurance staff. The state detects unauthorized
chemical and mechanical restraints by reviewing the CMHC’s risk management reports and processes, audits of
the CMHC’s, reports sent in by the CMHC or by individuals that reference a concern in this area.
36
Billing Information
Service Description Code Limitations/Requirements Unit Value
Short Term Respite Care S5150
Cannot be billed simultaneously with Professional
Resource Family Care. Overnight respite homes must
be licensed as family foster homes in accordance with
state statute and regulations. Waiver participants in DCF
custody placed outside the home are not eligible for this
service
1 unit = 15
minutes
Parent Support & Training-
Individual S5110 Cannot be billed simultaneously with PRFC
1 unit = 15
minutes
Parent Support & Training-
Group
S5110
TJ Cannot be billed simultaneously with PRFC
1 unit = 15
minutes
Independent Living/Skills
Building T2038
1 unit = 1
hour
Wraparound Facilitation H2021
There are no limits on Wraparound Facilitation.
Wraparound facilitation is to occur at the initial Person
Centered Service Plan/POC development and, at
minimum, yearly to review the PERSON CENTERED
SERVICE PLAN/POC or more frequently when changes
in the participant’s circumstances warrant. This service
must occur face-to-face.
1 unit = 15
minutes
Professional Resource
Family Care (PRFC) S9485
PRFC cannot be billed simultaneously with Short Term
Respite. PRFC homes must be licensed as family foster
homes in accordance with state statute and regulations.
Waiver participants in DCF custody placed out of home
are not eligible for this service.
1 unit = 1
day
Waiver Attendant Care T1019
HK
There are no limits to Attendant Care. Services provided
in an educational setting must not be educational in
nature or duplicate other Medicaid State Plan services.
1 unit = 15
minutes
37
Attachments: SED Manual Forms
SED Attachment A: Initial Clinical Eligibility Form
SED Attachment B: Request for Exception to Minimum Age Criteria
SED Attachment C: Initial Request for Exception to Age 18 Criteria
SED Attachment D: Request for Exception to CBCL Criteria
SED Attachment E: SED Waiver Annual Evaluation of Level of Care (LOC)
SED Attachment F: Provisional Plan of Care
SED Waiver Attachment A
Revised March 14, 2021 Page 1 of 7
INITIAL CLINICAL ELIGIBILITY FORM Complete all sections of this form and sign appropriately.
Consumer/Child/Youth Information
Last Name: First Name: Middle Initial:
Date of Birth: Address:
City, State: Zip: Phone #:
Email: Medicaid ID: SSN #:
KAMIS ID: Sex: KanCare MCO:
Education/Vocation Status: Primary Language:
DCF CUSTODY: YES: ☐ NO: ☐
Parent / Legal Guardian Information
Last Name: First Name:
Address: City, State:
Zip: Phone/Cell #: Email:
Community Mental Health Center (CMHC)
CMHC:
Address: City, State: Zip:
Phone #: Email Address: Completed By:
Complete the Sections Below
1. Is the child/youth at least 4 years old?
Yes: ☐
No: ☐ If NO: The child/youth does not meet SED Waiver minimum age criteria. If an exception to minimum age criteria will be requested, complete remainder of document.
2. Is the child/youth under 18 years of age?
Yes: ☐
No: ☐ If NO: The child/youth does not meet SED Waiver minimum age criteria. If an exception to maximum age criteria will be requested, complete remainder of document
SED Waiver Attachment A
Revised March 14, 2021 Page 2 of 7
3. Does the child/youth have a qualifying DSM diagnosis?
Yes: ☐
Diagnosis:
Date of diagnosis:
Name/Credentials/Agency/Telephone of diagnosing QMHP:
No: ☐ The child/youth does not meet SED Waiver criteria
4. Does the child/youth meet Serious Emotional
Disturbance (SED) criteria?
Yes: ☐
Date of determination of SED:
Name/Credentials/Agency/Phone# of QMHP making the SED determination:
No: ☐ The child/youth does not meet SED Waiver criteria.
5. Is the child/youth at risk for inpatient
psychiatric hospitalization in absence of SED
Waiver services?
Yes: ☐
No: ☐ The child/youth does not meet SED Waiver criteria.
Record CBCL and CAFAS or PECFAS Results below SED Waiver eligibility requires minimum scores on both Child Behavior Check List (CBCL), and the Child and Adolescent Functional Assessment Scale
(CAFAS) or Preschool and Early Childhood Functional Assessment Scale (PECFAS) as applicable.
6. CBCL (Valid if completed less than 6 months prior to Clinical Eligibility date.) Indicate t-scores and version used, as applicable.
CBCL TRF YSR
Internalizing
Externalizing
Total Problems
Date of CBCL:
7. Did the child/youth receive a score of at least 70 on any scale? (SED Waiver eligibility
Yes: ☐
SED Waiver Attachment A
Revised March 14, 2021 Page 3 of 7
requires a minimum score of 70 on at least one scale).
No: ☐
The child/youth does not meet SED Waiver criteria. An exception can be requested with A CBCL score of 63-69. An exception form is required. Complete remainder of document.
Request Exception: ☐
8. CAFAS or PECFAS (Valid if completed less than 3 months prior to clinical eligibility date.)
Scale Scores: Date of CAFAS/PECFAS:
School/Work Role Performance: Moods/Emotions:
Home Role Performance: Self-Harm:
Community Role Performance: Substance Abuse:
Behavior Towards Others: Thinking:
Total Score:
9. Did the child/youth receive a minimum Total Score of 100, or a score of 30 on each of any two sub-scales? (SED Waiver eligibility criteria require a minimum Total Score of 100, or a minimum score of 30 on each of any two sub-scales)
Yes: ☐
No: ☐ The child/youth does not meet SED Waiver criteria.
10. Is an exception requested for A request for an exception must include the completed Initial Clinical Eligibility Form and
Attachments B,C,D,E, as applicable. Exception Request and documents must be submitted via KAMIS to SED Waiver Program Manager for approval.
a. Minimum Age Yes: ☐ Complete Attachment B
No: ☐ Continue filling form
b. Age 18 Criteria Yes: ☐ Complete Attachment C or E (if applicable)
No: ☐ Continue filling form
c. CBCL Score Yes: ☐ Complete Attachment D
No: ☐ Continue filling form
CURRENT EVIDENCE SUPPORTING CHILD/YOUTH’S SED WAIVER STATUS (this form to be completed for all SED Waiver eligible individuals)
11. Description of specific behaviors/problems that put the child/youth at risk of inpatient psychiatric hospitalization without SED Waiver services.
SED Waiver Attachment A
Revised March 14, 2021 Page 4 of 7
12. Description the child/youth’s family and current living situation that support the need for SED Waiver services
13. Description of factors in the child/youth’s school/vocational placement that support the need for SED Waiver services
14. Description of other community risk factors that supports the child/youth’s need for SED Waiver services
SED Waiver Attachment A
Revised March 14, 2021 Page 5 of 7
QMHP name and credentials: Date:
QMHP signature and credentials:
QMHP Phone Number:
CMHC:
SED Waiver Designated Email Address:
CRITERIA FOR SERIOUS EMOTIONAL DISTRUBANCE (SED)- SED Waiver The term “Serious Emotional Disturbance” refers to a diagnosed mental health condition that substantially disrupts a child/youth's ability to
function socially, academically, and/or emotionally.
Complete the following checklist to determine if the child/youth has SED:
Child/Youth Name: CMHC:
Evaluator: Signature: Date:
AGE:
The child/youth is under age 18 or under the age of 22 and has been receiving community based mental health services prior to the age of 18 that must be continued for optimal benefit.
Yes: ☐ No: ☐
DURATION and DIAGNOSIS:
The child/youth currently has a diagnosable mental, behavioral, or emotional condition of sufficient duration to meet the diagnostic criteria specified within the most current DSM.
Disorders include those listed in the most current DSM or the ICD-9 equivalent with the exception of DSM “V" codes, substance abuse or dependence, and developmental disorders, unless they co-occur with another diagnosable disorder that is accepted within this definition.
Yes: ☐ No: ☐
FUNCTIONAL IMPAIRMENT:
The disorder must have resulted in functional impairment which substantially interferes with or limits the child/youth's role or functioning in family, school, or community activities.
Functional impairment is defined as difficulties (internalizing and externalizing) that substantially interfere with or limit a child/youth from achieving or maintaining one or more developmentally appropriate social, behavioral, cognitive, communicative, or adaptive skills. Functional impairments of episodic, recurrent and continuous duration are included.
Children/Youth that would have met functional impairment criteria without the benefit of treatment or other support services are included in this definition.
Functional impairment does not qualify if it is a temporary response to stressful events in the child/youth's environment. Functional impairment also does not qualify if it can be attributed solely to intellectual, physical, or sensory deficits.
Yes: ☐ No: ☐
SED Waiver Attachment A
Revised March 14, 2021 Page 6 of 7
Which of the following functional areas has been disrupted as a direct result of the child/youth's mental health condition? (Examples are not intended to be all inclusive and more than one can be marked).
School
for example: exhibiting behaviors that interfere with the xchild's ability to perform, such as inattentive in class, unable to sit in one place, unable to concentrate, withdrawn at school to the point that the child's ability to function at school is impacted, accumulating sick days as a result of being overwhelmed/depressed which places the student at risk for truancy, in-school suspension, out-of-school suspension
Family
for example: at risk of out of home placement, physical aggression at home, suicidal, isolative and withdrawn to the
point that youth is not engaging in day to day family activities.
Community for example: impairment necessitates law enforcement contact such as youth is running away due to delusional symptoms; unable to or serious difficulty participating' in regular community and/or peer activities due to behavior, isolating from peers.
SED Waiver Attachment A
Revised March 14, 2021 Page 7 of 7
Upload the following documents to client’s KAMIS account:
☐ Initial Clinical Eligibility Packet
☐ SED Determination Form
☐ Qualifying CAFAS
☐ Qualifying CBCL
☐ Strength and Needs (for MCO)
☐ Provisional Plan of Care
☐ Exception Request forms as needed
Email to [email protected] the following:
☐ Provisional Plan of Care
☐ 3160
SED Waiver Attachment B
Revised November 19, 2020
REQUEST FOR EXCEPTION TO MINIMUM AGE CRITERIA – SED
Waiver
Child/Youth Name: __________________________________________ Date: ___________________ Child/Youth DOB: _______________ Date of Clinical Eligibility Assessment: ___________________
1. Does the child meet SED criteria, Initial Clinical Eligibility, CBCL and PECFAS criteria?
• ☐Yes, proceed to question 2. • ☐No, Child/youth is not eligible for HCBS SED Waiver.
2. Describe the child/youth’s functioning that indicates the need for an inpatient
psychiatric hospital (e.g. harmful behavior to self or others, psychotic symptoms, aggression, etc.)
3. Describe the child/youth’s behavior at home and in the community that indicates the child/youth is at risk for inpatient psychiatric hospitalization (extensive supervision by others is needed due to potentially dangerous behaviors; constant clinging behavior; extreme temper tantrums, stealing, etc.)
4. Describe the child/youth’s behavior toward others that indicates risk of inpatient psychiatric hospitalization (bizarre and disruptive behavior, deliberate cruelty to animals, lack of age-appropriate peer interactions, threats, stealing.)
5. Describe the child/youth’s moods/emotions that indicate risk of psychiatric
hospitalization (anxiety, depression, panic, fear, etc.) as demonstrated by odd behavior, marked distress, excessive crying, sadness accompanied by suicidal wish, etc.
SED Waiver Attachment B
Revised November 19, 2020
QMHP Signature/Credentials __________________________________ Date_______________ This form must be submitted via KAMIS Exception Request along with all required documentation outlined in Initial Clinical Eligibility Packet.
SED Waiver Attachment C
1 Attachment C doc 4.13.21
INITIAL REQUEST FOR EXCEPTION TO AGE 18 CRITERIA SED Waiver
Child/Youth Name: _______________________________________ Date: ___________________ Child/Youth DOB: ______________ Date of Clinical Eligibility Assessment: _________________
1. Does the child meet SED criteria, Initial Clinical Eligibility, CBCL, CAFAS?
☐ Yes Child/youth is eligible for the HCBS SED Waiver. Proceed to Question 2
☐ No Child/youth is not eligible for the HCBS SED Waiver. STOP
2. Has the child/youth been identified as SED and has the child/youth received community-based services any time during the six months prior to turning age 18, or would have the child/youth accessed community-based services during that time period if not for their institutional or residential status?
☐ No Child/youth is not eligible for an exception to age 18 criteria. STOP ☐ Yes Child is eligible and has received community-based services in the
past 6 months prior to turning 18 ☐ Yes Child is eligible but has not been able to access community-based
services to institutional/residential status. Dates of institutional/residential status:
Community-based services (CBS) are defined as anyone or combination of the following services:
• Targeted Case Management • Community Psychiatric Supportive Treatment (CPST) • Psychosocial Rehabilitation -Group • Psychosocial Rehabilitation Individual, • Attendant Care
3. Community-based services provided during the 6 months prior to turning 18 were:
Service Start Date Date of most recent use Targeted Case Management (TCM)
SED Waiver Attachment C
2 Attachment C doc 4.13.21
Community Psychiatric Supportive Treatment (CPST)
Psychosocial Rehabilitation-Individual (PRI)
Psychosocial Rehabilitation-Group (PRG)
Attendant Care (AC)
Comments: This form must be submitted via KAMIS Exception Request along with all required documentation outlined in Initial Clinical Eligibility Packet.
The age exception must be approved annually. See SED Waiver Manual for further information.
SED Waiver Attachment D
Revised November 19, 2020
REQUEST FOR EXCEPTION TO CBCL CRITERIA – SED Waiver
Child/Youth Name: ______________________________________________ Date: _______________
1. Does the child/youth meet the SED Initial Eligibility and CAFAS criteria. • ☐Yes, Proceed to question 2 • ☐No, The Child/youth is not eligible for HCBS SED Waiver
2. A minimum score of 70 on the CBCL was not attained. Was a score of 63-69 attained for the child/youth on the Internalizing, Externalizing, or the Total Problems sub-scale?
• ☐Yes, Document reasons for CBCL exception below. • ☐No, The child/youth does not meet SED Waiver criteria.
3. Explain why the CBCL minimum score criteria should be excepted. For example,
describe circumstances that interfere with attaining the minimum CBCL score, or clinical observations that support exception of the minimum score.
4. Has there been a CBCL in the 6 months previous to this current clinical assessment that did attain a score of 70 or higher?
☐ No ☐ Yes Date completed: _____________________ QMHP Signature, Credentials _____________________________________ Date: ______________ This form must be submitted via KAMIS Exception Request along with all required documentation outlined in Initial Clinical Eligibility Packet.
SED Waiver Attachment E
Revised April 6, 2021
ANNUAL EVALUATION OF LEVEL OF CARE (LOC)- SED Waiver
Name of child/youth: ___________________________________________________________ D.O.B: _________________________ Medicaid ID No: _____________________________ ☐ Youth is 18 or older at the time of this Annual LOC (Complete Section C) Clinical Eligibility Date: ____________________ Previous Annual LOC Date (if applicable): ____________________ Requirements of the SED Waiver Annual Evaluation of Level of Care: • This evaluation should reference the previous six months. It must be conducted by a
Qualified Mental Health Professional responsible for overseeing the SED Waiver clinical eligibility. It must be filed in the child/youth's clinical chart.
• The date for annual review must occur within 364 days from the clinical eligibility date or previous annual LOC date, Annual LOC may be completed only within the 30 days prior to annual initial clinical eligibility date or previous annual LOC date
• If youth has reached their 18th birthday at the annual review time the youth must receive approval to continue the SED Waiver by the KDADS SED Waiver Program Manager and all subsequent LOCs after.
• Persons who have reached their 22nd birthday are no longer eligible for the SED waiver. Complete the following:
1. Does the child/youth have a qualifying DSM-5 diagnosis (ASD cannot be the only
diagnosis) ☐ Yes, go to #2 ☐ No, proceed to section B.
2. Does the child/youth meet criteria for Serious Emotional Disturbance? ☐ Yes, go to #3 ☐ No, proceed to Section B.
3. Does the child/youth continue to need SED Waiver services in order to maintain the child/youth in the community and avoid inpatient Psychiatric Hospitalization? ☐ Yes, proceed to Section A ☐ No, proceed to Section B.
Section A: - YES, Youth continues to meet functional eligibility for the SED Waiver.
1. Describe in detail how the child/youth continues to be at risk for Inpatient Psychiatric Hospitalization without SED Waiver services. The identified symptoms should be included in the rationale. Use additional pages as needed.
2. Describe in detail the SED Waiver services that have impacted the Child/youths functional
SED Waiver Attachment E
Revised April 6, 2021
impairment and ability to maintain in the community. The waiver services are Parent Support, Attendant Care, Short Term Respite Care, Wraparound Facilitation, Independent living/skills building and Professional Resource Family Care. Use additional pages as needed. Section B:
1. Describe in detail the clinical rationale that supports the child/youth is not at risk for Inpatient Psychiatric Hospitalization and no longer eligible for the SED Waiver.
2. Inform family that youth no longer qualifies for SED Waiver. Send a closure 3161 to KDHE designated mailbox to review and complete closure of SED Waiver.
QMHP Signature and Credentials: ___________________________ Date: _____________ Section C: Over 18 Exception Approval Enter Over 18 Exception Request in KAMIS as follows:
1. Complete a 3160 form and indicate in comments “Over 18 Youth continues to meet clinical eligibility for SED Waiver.”
2. Within KAMIS, complete: - Create an “SED Waiver Exception Request” in youth’s KAMIS account. - Enter most recent CBCL and CAFAS scores (Needed for CMS - This will NOT affect eligibility) *KDADS will pull initial CAFAS and CBCL from KAMIS if they do not already have this from initial eligibility. - Select “Exception to age 18 criteria” box and “Create” – select “YES”
3. Attach to exception request and SUBMIT:
In the text box in KAMIS put “Over 18 ongoing eligibility”. Then upload the following: - Most recent Annual Level of Care (ALOC) document (this document).
SED Waiver Attachment E
Revised April 6, 2021
- Most current CAFAS - Most current CBCL
4. Assist youth in completing a KanCare Online Medicaid application in their own name before they turn 19, or if their financial eligibility has been termed.
5. Email [email protected] the 3160 and inform the exception is request for “ongoing over- 18 eligibility”.
6. KDADS will review request and approve or ask for more information if needed. KDADS will
sign 3160 Section III and forward to KDHE for financial eligibility approval.
SED Waiver Attachment F
SERIOUS EMOTIONAL DISTURBANCE (SED) WAIVER PROGRAM
PROVISIONAL PLAN OF CARE JANUARY 2021
The Provisional Plan of Care is required by CMS as part of the eligibility process. The Provisional Plan of Care must be sent alongside the KDHE Form 3160 to KDADS designated mailbox at [email protected]. This form after completion, the ICE form, CAFAS Assessment, CBCL, and Strength and Needs forms must be uploaded into KAMIS.
Consumer Information
*Last Name: *First Name: *Middle Initial: *Date of Birth:
*Address: *City, State: *Zip: *Phone #:
*KAMIS ID: *Medicaid ID: *KanCare MCO: *SSN #:
Parent / Legal Guardian Information
*Last Name: *First Name: *Address:
*City, State: *Zip: *Phone #: Cell #:
COMMUNITY MENTAL HEALTH CENTER (CMHC)
*CMHC: *Address: *City, State:
*Phone #: *Email Address: *Completed By:
*required fields if known
SERVICE UNIT/DURATION UNITS OF SERVICES CHECK
ATTENDANT CARE (T1019 HK) 1 Unit = 15 Minutes FOR # UNITS
INDEPENDENT LIVING / SKILLS BUILDING (T2038)
1 Unit = 1 Hour
FOR # UNITS
PARENT SUPPORT TRAINING (INDIVIDUAL) (S5110)
1 Unit = 15 Minutes FOR # UNITS
PARENT SUPPORT TRAINING (GROUP) (S5110 TJ)
1 Unit = 15 Minutes FOR # UNITS
PROFESSIONAL RESOURCE FAMILY CARE (S9485)
1 Unit = 1 Day FOR # UNITS
SHORT TERM RESPITE CARE (S5150) 1 Unit = 15 Minutes FOR # UNITS
WRAPAROUND FACILITATION (mandatory) (H2021)
1 Unit = 15 Minutes FOR # UNITS
TOTAL MONTHLY UNITS FOR ALL SELECTED SERVICES
= # UNITS Comments:
KDADS SED Form/Provisional Plan of Care v.2 rev.12/10/21